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Health Insurance and the Patient's Bill of Rights

MedSave Admin | February 22, 2010

The Patient's Bill of Rights (PBR) can be an effective tool to help consumers better understand their health insurance, and the business transactions that affect the quality of their health care. PBRs have been discussed recently as one tools that may be further developed as part of national health care reform.

First, it is important to recognize that there is no single or uniform PBR in the US. The term is used generically in this context to refer to many different statements. Every doctor, hospital, medical practice, or government entity may have a unique PBR statement.

Additionally, there is no requirement that any government or private entity have a unique PBR--other than the requirement to abide by the law or the regulations of a controlling affiliation.

Legally enforceable PBRs are included in many states' laws and there are several federal laws, including the Consumer Bill of Rights and Responsibilities of 1998 and the Patient Safety Act of 2005, and most recently, the extensive provisions Health Insurance Portability and Accountability Act (HIPAA) in 1996.

With state specific regulations and several national laws, it is easy to see how the subject of a PBR can become quickly muddied. The US Congress tried, but failed, to pass a universal version of the PBR in 2002. Some states like Michigan seized the opportunity to make a political statement by issuing a meandering message to consumers.

Since then, it seems that most health care entities have adopted some form of a PBR with similar format and intent. Here we highlight the features of a PBR that may have the most potential to benefit individuals in understanding and dealing with their health insurance.

One of the most strongly worded PBRs, aimed at protecting consumer rights, has been adapted by the American Association of Physicians and Surgeons (AAPS) and specifically details the disclosures that must be made to patients about the business relationship between the insurance company and their physician. This PBR has been selected as an example to show the potential of these disclosures to empower consumers.

The AAPS adopted the following PBR in 1995:

All patients should be guaranteed the following freedoms:

  • To seek consultation with the physician(s) of choice;
  • To contract with their physician(s) on mutually agreeable terms;
  • To be treated with confidentiality, with access to their records limited to those involved in their care or designated by the patient;
  • To use their own resources to purchase the care of their choice;
  • To refuse medical treatment even it if is recommended by their physician(s);
  • To be informed about their medical condition, the risks and benefits of treatment and appropriate alternatives;
  • To refuse third-party interference in their medical care, and to be confident that their actions in seeking or declining medical care will not result in third-party imposed penalties for patients or physicians;
  • To receive full disclosure of their insurance plan in plain language, including:

    1. Contracts: A copy of the contract between the physician and health care plan, and between the patient or employer and the plan;
    2. Incentives: Whether participating physicians are offered financial incentives to reduce treatment or ration care;
    3. Cost: The full cost of the plan, including co-payments, coinsurance, and deductibles;
    4. Coverage: Benefits covered and excluded, including availability and location of 24-hour emergency care;
    5. Qualifications: A roster and qualifications of participating physicians;
    6. Approval Procedures: Authorization procedures for services, whether doctors need approval of a committee or any other individual, and who decides what is medically necessary;
    7. Referrals: Procedures for consulting a specialist, and who must authorize the referral;
    8. Appeals: Grievance procedures for claim or treatment denials;
    9. Gag Rule: Whether physicians are subject to a gag rule, preventing criticism of the plan.
Many patients are not even aware that these potential conflicts of interest between their doctor and health plan exist. Imagine the impact if the entire health care industry operated with the level of disclosure envisioned by the AAPS. Unfortunately, the AAPS represents only a small percentage of all practicing physicians in the US. By way of comparison, the largest physician association, the American Medical Association (AMA), claims about 20% of practicing physicians, and this larger association supports a PBR with much weaker language.

Although we are not aware of any other PBRs worded as strongly as the one advocated by the AAPS, most do contain some element of disclosure that may pave the way to consumer empowerment. While the potential benefits to consumers may be clear, we have yet to see whether the expansion or utilization of PBRs may be a part of future health care reform.

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